Indirect Measurement of Arterial Blood Pressure



Indirect Measurement of Arterial Blood Pressure

EKG Analysis, Cardiovascular Index, Mammalian Diving Reflex

Purpose: This exercise is designed to familiarize the student with indirect blood pressure measurements, taking an EKG, measuring cardiovascular fitness and observing the phenomenon known as the Mammalian Diving Reflex.

Performance Objectives: At the end of this exercise the student should be able to:

1. Take indirect blood pressure measurements.

2. Take an EKG of another person using the stand limb leads and IWORX equipment.

3. Describe the auscultatory and palpatory methods of measuring blood pressure.

4. Define bradycardia, tachycardia, systolic, diastolic, sphygmomanometer, Korotkoff sounds.

5. Describe how to calculate cardiovascular index.

6. Explain and demonstrate the Mammalian Diving Reflex.

7. Calculate heart rate given the duration of the cardiac cycle.

8. Identify the P, QRS, T wave forms of an EKG.

9. Describe what each wave form of the EKG represents.

Introduction:

BLOOD PRESSURE (BP) is caused force of the blood pushing against the vessel walls. In the systemic circulation, this pressure is highest in the arteries and lowest in the veins. As a result, the blood moves from the arteries through the organs into the veins and back into the heart to begin the cycle over again. The heart acts as a pump to create the high arterial pressures that keep the blood flowing.

Because it is the force that pushes the blood through the organs, the ARTERIAL BLOOD PRESSURE is of critical importance and is frequently measured by health professionals. It is critical that this pressure remain relatively stable. If it is chronically too low, insufficient blood will be pushed through organs and the cells will receive an inadequate supply of oxygen and nutrients. On the other hand, a chronically elevated arterial blood pressure (HYPERTENSION) can damage the blood vessels and increase the risk of stroke. High arterial pressure also puts an added strain on the heart because it must overcome the pressure in the arteries before it can force new blood into the system. The following table describes blood pressure categories defined by the American Heart Association.

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The blood pressure in the arteries rises and falls with the phases of the heart beat. The highest pressure in the arteries, produced by ventricular contraction is known as the SYSTOLIC BLOOD PRESSURE. The lowest pressure in the arteries, produced by ventricular relaxation is known as the DIASTOLIC BLOOD PRESSURE. The difference between the systolic and the diastolic pressure is known as the PULSE PRESSURE. The average effective arterial pressure forcing blood through the organs is known as the MEAN ARTERIAL BLOOD PRESSURE. This is approximated taking the diastolic pressure and adding 1/3 of the pulse pressure.

The blood pressure in the arteries may be measured either directly or indirectly. In the DIRECT METHOD, a fluid-filled cannula is inserted into an artery and the direct, head-on pressure of the blood is measured with a pressure transducer. In the INDIRECT METHOD, no contact is made with the blood. Instead, pressure is applied externally to an artery occluding it and stopping blood flow. Then the blood pressure is determined by listening to various arterial sounds (KOROTKOFF SOUNDS) that result when the external pressure is reduced and the blood begins to flow again. This is called the AUSCULTATORY METHOD since the detection of sound is called auscultation. An older, less accurate, indirect measure of arterial blood pressure is the PALPATORY METHOD in which one simply palpates or feels the pulse as the pressure applied externally to an artery is reduced. In the every day practice of medicine a combination of the palpatory and auscultatory methods is used. For obvious reasons, human blood pressure is very rarely measured directly. Fortunately, while indirect measurements of arterial blood pressure are less accurate than direct measurements, they come close enough to be clinically useful.

In both indirect methods pressure is applied externally to an artery using an instrument called a SPHYGMOMANOMETER. It consists of an inflatable rubber bag (cuff), a rubber bulb for introducing air into the cuff, and a mercury or aneroid manometer for measuring the pressure in the cuff. The cuff size used varies depending on the circumference of the arm. Cuff width should be approximately 46% of arm circumference.

Human blood pressure is most commonly measured in the BRACHIAL ARTERY of the upper arm. In addition to being a convenient position for taking measurements, it has the added advantage of being at approximately the same level as the heart so that pressures obtained closely approximate the pressures in the aorta leaving the heart. This allows the blood pressure to be correlated with heart activity.

Part I: Indirect Methods of Blood Pressure Measurement

1. Palpatory Method

Seat the subject comfortably with his RIGHT ARM resting on the laboratory table. The subject’s legs should not be crossed. This may raise systolic blood pressure 2 – 8 mmHg. Wrap the pressure cuff snugly around the bare arm above the elbow, making certain that the inflatable bag within the cuff is placed over the inside of the arm where it can exert pressure on the brachial artery. Secure the end with the Velcro flap. Have the cuff snug when deflated, but loose enough to avoid all possibility of interfering with the venous return from the forearm. Close the valve on the bulb by turning it clockwise. The diagram below shows the proper placement of the pressure cuff.

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With one hand, palpate (feel) the radial pulse in the wrist. Slowly inflate the cuff by pumping the bulb with the other hand, and note the pressure reading when the radial pulse is first lost. Then increase the pressure 30 mm Hg above this point. Slowly reduce the pressure in the cuff (2-3 mm Hg/heartbeat) by turning the valve counterclockwise slightly to let air out of the bag. Note the pressure when the radial pulse first reappears - this is the systolic blood pressure. Let all the air out of the cuff. Do not leave the cuff inflated for over two minutes, as it is uncomfortable and will cause a sustained increase in blood pressure.

The systolic pressure recorded by the palpatory method is usually around 5 mm Hg lower than that obtained using the auscultatory method. A major disadvantage of this method is that it cannot readily be used to measure diastolic pressure.

(Optional) Repeat the above procedure, only this time instead of palpating the radial artery; attach the index finger of the arm with the cuff to the photoelectric pulse pickup (PPG). Attach the pulse pickup to one of the channels of the IWORX. Increase the pressure an additional 30 mm Hg. above normal blood pressure. Slowly deflate the cuff (2-3 mm Hg/heartbeat) until the radial pulse reappears. Record the systolic pressure and compare it to the pressure obtained by direct palpitation.

Direct Palpation: ______________________ PPG: ________________________

2. Auscultatory Method for taking Blood Pressure

1. Position the patient's arm so the antecubital fold is level with the heart.

2. Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essential to obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.

3. Palpate the radial pulse and inflate the cuff until the pulse disappears. This is a rough estimate of the systolic pressure. At this point the brachial artery is occluded and blood flow and sound will stop.

4. Place the stethoscope over the brachial artery.

5. Inflate the cuff 20 to 30 mmHg above the estimated systolic pressure.

6. Release the pressure slowly, no greater than 3 mmHg per second.

7. The level at which you consistently hear beats is the systolic pressure. The sounds are heard are because of the blood spurting through the brachial artery causes turbulent flow with the sudden expansion and collapse of the arterial wall with each beat. The sounds are called Korotkoff sounds which were first described by KOROTKOFF in 1905 is described more completely below:

Phase 1 - The initial appearance of clear snapping sound which increase in intensity during the next 10 mm Hg of pressure drop. The pressure when these sounds first appear is the systolic pressure.

Phase 2 - The sounds decrease in pitch during the next 10-15 mm Hg drop in pressure. Often described as a murmur or swishing sound.

Phase 3 - The sounds become deeper and louder and crisper.

Phase 4 - The sound suddenly becomes muffled and distant. The pressure at this point is termed the diastolic pressure. This muffled sound continues for another 5 mm Hg pressure drop, after which the

sound disappears. This point is called the end-diastolic pressure. It is sometimes recorded along with the systolic and diastolic pressure in this manner: 120/80-75 mm Hg.

Phase 5 - Silence

8. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure

9. Record the blood pressure as systolic over diastolic (120/70).

10. Blood pressure should be taken in both arms on the first encounter.

4. Before proceeding make several blood pressure determinations on a willing subject using the sphygmomanometer. Practice until you can obtain accurate, consistent readings. Compare the systolic pressure measurements determined by the palpatory and auscultatory methods. If you are having difficulty taking blood pressure use the automatic device as shown below; then practice with the stethoscope and pressure cuff during open lab.

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5. Using the sphygmomanometer do each of the following experiments, record the data in the spaces provided and explain the results.

a. Postural Effects on Blood Pressure

Determine the blood pressure (systolic and diastolic) and the pulse rate after your subject has rested quietly for several minutes in a supine (lying down) position. Do this several times until constant values are obtained. Wait at least 1 minute between trials.

Trial 1 Trial 2

Supine BP

Pulse Rate

Determine the blood pressure (systolic and diastolic) and the pulse rate again immediately after your subject changes from the supine to the stand-up position. Repeat as necessary.

Trial 1 Trial 2

Stand-up BP

Pulse Rate

Note the effects of postural change on blood pressure and explain:

b. Cold Pressor Test

Let the subject lie comfortably on the laboratory table for a few minutes. Place a pail of cold water (5o C or lower) on the table next to him or her. Record the blood pressure and pulse rate repeatedly until stable pressures are obtained.

Trial 1 Trial 2

Supine BP (resting)

Pulse Rate (resting)

After the control period, submerge the subject's free hand in the cold water to well above the wrist. Record the blood pressure and carotid pulse rate at 30 second intervals for 1 1/2 minutes. All recordings should be homolateral to the cold pressor stimulus.

30 secs 60 secs 90 secs 120 secs

Supine BP (cold water)

Pulse Rate (cold water)

What happens initially to the blood pressure and pulse rate after the wrist is immersed in the cold water?

Explain the physiological mechanism behind this response:

Does the blood pressure return to normal while the hand is immersed in the cold water?

If so, how

long does it take?

Explain why this occurs:

c. Isometric Exercise and Blood Pressure

Record a baseline blood pressure and pulse rate while the subject is in a standing position.

Standing BP (resting)

Pulse Rate (resting)

Have the subject arm curl a heavy barbell four times. After the fourth curl, quickly measure the blood pressure and pulse rate while the barbell is in the "up" position. Do not flex your arm so that the stethoscope or sensor in the automatic cuff is constricted.

Standing BP (during a curl)

Pulse Rate (during a curl)

What happens to the blood pressure and pulse rate during the curl?

Explain why this response occurs:

d. Activity and Blood Pressure

Record a baseline blood pressure and pulse rate while the subject is in a standing position.

Standing BP (resting)

Pulse Rate (resting)

Disconnect the manometer form the sphygmomanometer cuff and have the subject exercise sing the step or bicycle. When the subject returns quickly connect the manometer to the cuff again and record the blood pressure before the subject has a chance to recover.

Standing BP (exercise)

Pulse Rate (exercise)

What happens to the blood pressure during vigorous exercise?

Explain:

Post Exercise Systolic Blood Pressure Ratio (optional if time permits)

The post exercise systolic blood pressure ratio (SBPR) is an expression of the rate of decline of the post exercise blood pressure relative to the peak exercise value. The 3-min systolic blood pressure ratio is a useful and readily obtainable measure that can be applied in all patients who are undergoing exercise testing for the evaluation of known or suspected ischemic heart disease. The ratio is calculated by dividing the systolic blood pressure 3 min into the recovery phase following peak exercise by the systolic blood pressure at peak exercise. A 3-min systolic blood pressure ratio greater than 0.90 is considered abnormal. Higher values for the ratio are associated with more extensive coronary artery disease, as well as an adverse prognosis after myocardial infarction.

Systolic Blood Pressure Ratio: _____________________________

Auscultation

A. While the stethoscopes are available, listen to the heart sounds that are described in your lecture notes. Recall that the FIRST HEART SOUND (the lub) is produced at the onset of ventricular systole when the AV valves close. The SECOND HEART SOUND (the dub) is produced at the onset of diastole when the aortic and pulmonary semi-lunar valves close.

B. The diagram below shows the AUSCULTATORY AREAS on the chest where the sounds from each valve can be heard most clearly. Note that the valve sounds are not loudest directly over their anatomic locations. Move the stethoscope around on the chest and listen for changes in sound intensity and duration.

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What is a murmur?

Did you hear any?

Part II: EKG and Arterial Pulse Pressure

EKG

Purpose: This exercise is designed to familiarize the student with taking an EKG and observing the phenomenon known as the Mammalian Diving Reflex.

Performance Objectives: At the end of this exercise the student should be able to:

1. Take an EKG of another person using the stand limb leads and IWORX equipment.

2. Explain and demonstrate the Mammalian Diving Reflex.

3. Calculate heart rate given the duration of the cardiac cycle.

4. Identify the P, QRS, T wave forms of an EKG.

5. Describe what each wave form of the EKG represents.

Background

Activity stimulates the heart to contract more vigorously than it does when the body is at rest. The EKG (electrocardiogram) sensor measures cardiac electrical potential waveforms (voltages) produced by the heart as its chambers contract. The EKG does not directly measure of heart muscle activity. A comparison of the EKG measured during rest and the EKG measured after mild exercise show the changes that take place in the heart cycle due to activity.

The Electrocardiogram

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The part of the EKG (electrocardiogram) before any measurement is taken is called the baseline.

The first deviation from the baseline (isoelectric point) in a typical EKG is an upward pulse following by a return to the base line. This is called the P wave and it lasts about 0.04 seconds.

After a return to the baseline there is a short delay while the heart’s AV node depolarizes and sends a signal along the atrioventricular bundle of conducting fibers (Bundle of His) to the Purkinje fibers, which bring depolarization to all parts of the ventricles in a wave that is almost simultaneous.

When the AV node depolarizes there is a downward pulse called the Q wave. Shortly after the Q wave there is a rapid upswing of the line called the R wave followed by a strong downswing of the line called the S wave and then a return to the baseline. These three waves together are called the QRS complex. This complex is caused by the depolarization of the ventricles and is associated with the contraction of the ventricles.

Next there is an upward wave that then returns to the base line. This upward pulse is called the T wave and indicates repolarization of the ventricles.

The sequence from P wave to T wave represents one heart cycle. The number of such cycles in a minute is called the heart rate and is typically 70-80 cycles (beats) per minute at rest.

P-R interval... 120-200 milliseconds (0.120 to 0.200 seconds)

QRS interval... under 100 milliseconds (under 0.100 seconds)

Q-T interval... under 380 milliseconds (under 0.380 seconds)

A. Activity: EKG and Finger Pulse: Baseline Recordings

The IWorx system will be used to record individual EKG’s and finger pulses. Each student should make a baseline recording of their own EKG and finger pulse.

Each student should only use ONE set of electrodes for EKG, do not remove

them until you are finished with this exercise

1. The equipment should be set up and preprogrammed for you.

2. Prepare the subject for recording by having them remove all jewelry from wrists and ankles. Then swab the ventral surface of each wrist and an area on the left leg just above the ankle with an alcohol swab. You will only be using three of the leads.

3. Place the plethysmograph (PPG) on the volar surface (area of fingerprint) of the distal segment of the index or thumb finger and wrap the Velcro to attach the unit firmly to the end of the finger.

Plethysmograph can be used to record changes in blood volume as the arterial pulse expands and contracts the microvasculature.

4. Have the subject to sit quietly with hands in their lap

5. Click and, if needed, in the channel two title area

6. You should see a rhythmic EKG tracing and pulse appear on the screen if the trace is upside down, click and switch the positive and negative electrode leads or right click and . If a cleaner signal is required, the electrodes should be moved from the wrists to the area immediately below each clavicle and the ground next to the umbilicus.

7. When you are getting a suitable trace, type the “’subjects name’ and ‘resting’” and press

Enter on the keyboard.

8. Click to halt recording

9. Proceed to the data analysis section of the exercise

8. Proceed to the data analysis section of the exercise

9. Each student should print a copy of their resting EKG, label the major waves on their EKG and paste one in the indicated space.

10. To save a picture of the EKG: Go to file, export and save as Jpeg on a flash drive or desktop. Email the picture to yourself and then print at home or on the lab printer. If the picture is placed in a word document, it can be resized to fit the indicated space.

|Place Tracings Here |

B. Determining heart rate.

1. Determine the heart rate as follows:

Heart rate = 60 sec./min.

(beats / minute) time interval between successive intervals in seconds. (R-R interval)*

*This is the heart rate at one moment in time, for a more reliable estimation of heart rate take the average of 10, R-R intervals.

Heart Rate (EKG) using 1, R-R interval: ________________

Heart Rate (EKG) using 10, R-R intervals: ______________

Using the formula above, calculate heart rate using two peaks from the pressure waves of the PPG, or again for a better estimate use the average of 10 wave forms.

Heart Rate (PPG) using 1, R-R interval: _______________

Heart Rate (PPG) using 10, R-R intervals: ______________

2. Pick one complete cycle (Heart Beat) and calculate the time difference between the generation of a heart beat and the actual pulse (PPG).

1. Press the 2-cursor icon and place one cursor on the peak of the QRS wave in channel1

2. Place the other curser in the peak of the finger pulse in window #2

3. Find the time difference in the T2-T1 window; this is a rough estimate of the time it took for the pressure pulse generated by the heart to reach the artery in your finger

Time Difference: _________________

3. Let the EKG run for approximately 10 seconds and watch for a normal rhythm (If an arrhythmia is present, call your instructor to verify). Also observe the relationship between atrial and ventricular rhythms.

_____________________________________________________________

_____________________________________________________________

4. Record the EKG and pulse of a student lying down after resting quietly for a few minutes. Then have the student stand quickly. Observe differences in the heart rate. Explain.

HR (Lying Down): _____________ HR (Standing): ________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

5. Describe the effect of exercise on the EKG. Make sure the electrodes are securely placed, disconnect the leads from the at the limb electrodes and allow the subject to engage in several minutes of vigorous exercise, preferably by placing one foot on a chair and raising and lowering the body repeatedly. Rapidly return the subject to the supine position; reconnect the limb leads. Why is speed essential in re-connecting the subject to the EKG?

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

C. Calculating Intervals from the EKG

1. Determine the P-Q interval from your EKG and record the time.

2. Determine the Q-T interval from your EKG and record the time.

3. Determine the R-R interval and record the time in the table below.

|Item |Rest (sec) |Exercise (sec) |

|P - Q interval | | |

|Q -T interval | | |

|R -R interval | | |

Compare your values for the P-Q, and Q-T intervals for the EKG at rest to the values for the P-Q, and Q-T intervals for the EKG after mild exercise. How do the time intervals for the EKG after mild exercise compare to the time intervals for the EKG at rest? Explain the differences.

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

What percent of the time are the ventricles contracting? Use the QT interval to help you with the calculation.

______________________________________

Part III: The Mammalian Diving Reflex

Using a student volunteer, the instructor will demonstrate the Mammalian Diving Reflex

A sphygmomanometer, stethoscope, IWORX System alcohol swabs, and volunteer are needed for the test. A pan of ice water, pan of room temperature water and towels are needed, along with all the previously mentioned materials, to demonstrate the diving reflex.

Initially, a three lead EKG is performed on a subject that is sitting and resting with their arms resting on their thighs breathing normally. For the diving reflex, the subject is asked to hold their breath and then immerse their entire face (including forehead) into the pan of ice water while continuing to hold their breath as long as possible. The EKG and blood pressure “before and after” results are recorded.

Heart Rate at end of breath holding in warm water: _____________

Heart Rate at end of breath holding in cold water: ______________

Part IV: Harvard Step Test

INTRODUCTION

The Harvard Step Test was developed in the Harvard Fatigue Laboratory in World War II to screen men for physical fitness and to evaluate the progress of physical training programs. The Harvard Step Test measures general endurance or physical condition.

The test consists of having the subject step up and down on a bench 20" high (16" for women) for 5 minutes, if possible and then measuring heart rate recovery during a post-exercise period. Subjects should stop if they feel that they cannot continue1. This exercise should only be done by those individuals who are in good physical health.

PROCEDURE

1. The subject stands in front of a bench of appropriate height. An observer stands behind the subject. The subject steps up and down on the bench at a rate of 30 steps (all the way up and down constitutes one step) per minute for a maximum of 5 minutes. The observer should watch the subject to insure the subject maintains the correct pace. The observer should also watch the subject to prevent accidental falls.

2. When the subject stops at the end of 5 minutes or sooner if the subject cannot keep pace, the subject should relax while the observer gets ready to take the subject's pulse. The duration of the exercise should also be noted.

3. Taking the Pulse:

A. One minute after finishing the test take your pulse rate (bpm)- Pulse 1

B. Two minutes after finishing the test take your pulse rate (bpm) - Pulse 2

C. Three minutes after finishing the test take your pulse rate (bpm) - Pulse 3

4. The physical fitness index is computed from the following formula:

Index = duration of the exercise in seconds x 100

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2 (Sum of Pulse 1, Pulse 2, Pulse 3)

5. Interpretation of Scores:

Gender |Excellent |Above Average |Average |Below Average |Poor | |Male |>90 |80-90 |65-79 |55-64 |86 |76-86 |61-75 |50-60 | ................
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